A Step in the Right Direction for Those Who Value Patient Safety

1.23.2020 By Liz Johnson, MS, FAAN, FCHIME, LCHIME, FHIMSS, CHCIO, RN-BC, Retired CIO

Patients die and suffer harm every day in our hospitals and health systems because of a longstanding ban that has haunted care in this country for decades. Although Congress allowed the ban to remain in place in the 2020 spending package, lawmakers also moved the needle by adding a directive to key agencies to explore methods that improve the identification of patients, which can include the evaluation of a patient identifier.

Here is the crux of the problem: We have no reliable way of verifying that the patient before our clinicians is the patient they see in their medical record. Language that has been inserted in appropriation bills since 1998 prevents the U.S. Department of Health and Human Services (HHS) from funding any effort to sincerely discuss how we can link patients to their records, let alone create and implement a unique patient identifier as was called for in the Health Insurance Portability and Accountability Act (HIPAA).

Here are some examples of the harm, distress and near misses resulting from patient misidentifications that CHIME members have shared:

• Two patients with the same name are on a wait list for a kidney transplant. Because of an identity mix-up, when a suitable donor kidney becomes available, the patient who is lower on the wait list gets the organ.
• A routine mammogram with a malignancy is misfiled under a deceased patient with the same name. The mistake is not discovered until a year later, when the patient shows up for her annual physical. At this point, the cancer has spread beyond treatment.
• A mother whose daughter has died from a pediatric cancer continues to get reminder calls for appointments for a child with the same name.
• An insurance company denies the claim for an emergency appendectomy, saying the procedure had already been done. It turns out the patient’s brother had used his insurance card.
• An unresponsive trauma victim is brought in who has the same first and last name as a patient with a Do Not Resuscitate/Do Not Intubate order and records are pulled for the latter. Thanks to a fortuitous set of circumstances and quick-thinking staff, the discrepancy did not lead to denial of lifesaving care.
• Annie B. Smith gives birth to a healthy baby and is sent home, only to have Child Protective Services appear and take the baby away. One day earlier, Ann B. Smith had been treated in the ER for a cocaine overdose. Annie B. Smith is separated from her child for three weeks and the facility is sued because of the mix-up.

Those anecdotes are just the tip of the iceberg. In the 2016 National Patient Identification Report, 86% of nurses, physicians and IT professions said they had witnessed or heard of a medical error in their organization that resulted from misidentification. They estimated that 35% of denied claims were linked to inaccurate or incomplete patient information, at an average cost of $1.2 million a year.

In mid-December lawmakers unveiled proposals to fund the government for the remainder of fiscal year 2020. Among policy changes included in the spending package that would fund HHS was a new directive to HHS to “continue to provide technical assistance to private-sector-led initiatives to develop a coordinated national strategy that will promote patient safety by accurately identifying patients to their health information. Additionally, the agreement directs ONC (the Office of the National Coordinator for Health IT), in coordination with other appropriate Federal agencies, to provide a report to the Committees one year after enactment of this Act studying the current technological and operational methods that improve identification of patients. The report shall evaluate the effectiveness of current methods and recommend actions that increase the likelihood of an accurate match of patients to their health care data. Such recommendations may or may not include a standard for a unique patient health identifier.” The directive was signed into law on Dec. 20.

CHIME has long advocated for a national patient identification system to protect patients from harms that occur through misidentifications. We commend Congress for recognizing this as a significant patient safety issue and for encouraging HHS to explore solutions. While this directive is a step in the right direction, our journey is not over. CHIME will continue to work with policymakers to find a safe, reliable and affordable way to link patients to their data. Each day without a solution is a day that puts countless patients at needless risk.

Editor’s note: This article was published previously in healthsystemCIO.com.